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TOWN OF NORTH ANDOVER
A
' PERMIT FOR GAS INSTALLATION
This certifies that ............ , !?!e; ... ...... .. .
has permission for gas installatio-?
in the buildings of ..... leer�,Ilc. `' ........................... .
at ...? ..�r.......... ,, North Andover Mass.
Fee.4 'P. Lic. No.
GAS INSPECTOR
Check # %%�
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:; Q C C6 Akb Date: /meq 1 Permit#
Building Locatio.Owners Name•;_.
Type of Occupancy: Commercial_ Educational._ Industrial Institutional. _ ' Residential I/
New Alteration:` Renovation: Replacement: Plans Submitted: Yes No
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No _
If you have checked Yes. please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ✓ Other type of indemnity . Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ° ; -
Signature of Owner or Owner's Agent - Agent
By checking this box ❑;1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and
aCCUrate to the best Of mv. Knnwladno And #hi f .tt
-- ---------a ------ -----••---•..... .., p....-- w.uo. u.c eu"iytssueo ror znis appilcauon wiii be in
compliance with all Pertinent provision of the Massachusetts State Plumbing _and C4apia?.1�2 Ofjthe General Laws.
A I) .
B lk
Type of License; / _..
y _ Plumber ✓ L„ -
Title ; Gas Fitter - _
Zr�B.�Z _ . Master Si nature of Licensed Plumber/Gas Fitter
_. _.
Journeyman
cityrrown .. , , _ _ yalle License Number: /6 � ?
APPROVED OFFICE USE ONL LP Installer
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BASEMENT
15T FLOOR
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FLOOR
3RD FLOOR
--i'FLOOR
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5 FLOOR
6 FLOOR
_.7 FLOOR
8 FLOOR
Check One,Onl ..:Certificate # � ',....
1nstailing Company.,Name Y
;
C orporation
Address d.e U State. MA
Partnership
Business Tel-�S�-SItS' Fax•.�'S 3 �ri�
Firm/Company
Name of Licensed Plumber/Gas Fitter: 6'�ll//iti
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes No _
If you have checked Yes. please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy ✓ Other type of indemnity . Bond
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ° ; -
Signature of Owner or Owner's Agent - Agent
By checking this box ❑;1 hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and
aCCUrate to the best Of mv. Knnwladno And #hi f .tt
-- ---------a ------ -----••---•..... .., p....-- w.uo. u.c eu"iytssueo ror znis appilcauon wiii be in
compliance with all Pertinent provision of the Massachusetts State Plumbing _and C4apia?.1�2 Ofjthe General Laws.
A I) .
B lk
Type of License; / _..
y _ Plumber ✓ L„ -
Title ; Gas Fitter - _
Zr�B.�Z _ . Master Si nature of Licensed Plumber/Gas Fitter
_. _.
Journeyman
cityrrown .. , , _ _ yalle License Number: /6 � ?
APPROVED OFFICE USE ONL LP Installer
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Board of: Health
North An4_0_v8_rzHa33-
-AP i► D UR
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INSTALLATICK CHECK LIST IM /1 <� /'
M_AJ1jL1jjCj1 .. ...........Og ML
iff SAY M
Reagmst
1. Distance Tot
a. Wetlands
b. Drains
c. Well
2. Water Line Location
3- No PVC Pipe
4. Septic Tank
a. -Tees -_Length &To Clean -Out Covers. ,
b. Cement Pipe to Tank - on Both Sides of Tank
5. Distribution Box
a. Covers & Box - NO Cracks
b. All Lines Flowing Equal Amounts
C. No Back Flow
69. Leach Field or Trench
a. Dimensions
b. Stone Depth
a*- Capped Bads.
d. Clean Double -Washed Stone'
7. Leach Pits -
a. Dimensions
b. Stone Depth
ceSplash Pads
d.
Tees
6. Cment pipe to Pit Both Sides.
f. Clean Double Washed Stone
8. No Garbage Disposal
9. nnal Grading Inspection
10, Barricading Covered System
11. As Built I Submitted.
a. Lot Location
b. Dimensions of System
c. Location _4th Regard_to Perc Test
d. Elevations
e; Water Table
t
R" rd of Health
No Andover,Mass
SUBSURFACE DISPOSAL DESIGN CHBCK LIST
2 M'V-_ ORM, M�
APPROOED
DATE
DISAPPROVED DATE
Provided:
Reasons:
4
Title V
FAIL
Cb, _
�'
Reg 2.5
The submitted plan must show as a minimums
a)
b
the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes -distance to ties
�c
location and results percolation tests -distance to ties
design calculations & calculations showing required leaching area
✓
(
location and dimensions of system -including reserve area
�f
existing and proposed contours
(g)
location any wet areas within 1001 of sewage disposal system or
disclaimer -check wetlands mapping
(h)
surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i}
location any drainage easements within 1001 of semge disposal
system r di -
sy em o disclaimer -Planning Board Piles
(j)
known sources of water supply within 2001 of sewage disposal .
system or disclaimer
A(
k)
location of a4.0roposed well to serve lot -1001 from leaching facility
�1)
location of water lines on property -101 from leaching facility
(m)
location of benchmark
✓
(n)
driveways
('o"
garbage disposals
(pr)
no PVC to be used in construction
71
(q)
profile of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
Other elevations
(r)
maximum ground water elevation in area sewage disposal system
(s)
plan mast be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Reg 6
Septic Tanks
(a)
capacities -150$ of flow, water table, tees, depth of tees,
(b}
access, pumping
cleanout
,/
(c)
lot from cellar wall or inground swivani ng pool
(d)
251 from subsurface drains
Reg 10.2- Distribution Boxes
(a) slope greater 0.08
Reg 10.4 1/ b) scup
Sti:irface Desi
FAIL
Regi 11.2
1.1.4
11.10
11.11
Reg 15.1
15.4
15.8
_ 3.7
Reg 14.1
14.3
14.4
14.6
14.7
14.10
Reg 9.1
9.6
Check List
OX
Leaching Pits
Page 2
Leaching pits are preferred where the installation is possible
a) calculations/of leaching area -m3.nimum 500 eq ft
b) spacing
nsurfac drainage 2%
cover'material
e) R�x2laltp splash pad
f) tee at elbow
g) rno bends in pipe from d -box to pipe
LeacMng Fields
a) no greater than 20 Vinutes/inch
lr area -minimum 900 eq ft
¢� construction of field
d) surface drainage 2 %
e) 202 from cellar all or ingxound mdxmdng pool
Leaching enches
a) c' ons of leaching area -min 500 eq ft
b) spac g-4 ft min 6 ft with reserve between
c ons
d) ccstraction
e)�stone
f} surface drainage 2%
VI
/ Downhill S��e
a .supe -y x be shown
b� y/x X 1 (to be shown
a)app val
b) strand -by power